Blog

The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

December 2021

How Much Psychotherapy is Necessary?

Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 4.

The question of how many psychotherapy sessions are necessary to achieve good patient outcomes, or how frequently sessions should occur has been on the minds of practitioners and researchers for over a century. In this part of the chapter, Lutz and colleagues review some of the research related to how many sessions of psychotherapy is necessary to achieve positive outcomes for patients. A meta-analysis of 70 randomized controlled trials (RCT) of psychotherapy did not demonstrate any correlation between the number of sessions a patient receives and their outcomes. Other research indicates that receiving psychotherapy twice a week is more effective than receiving treatment once a week for depression. The findings of these two lines of research suggest that treatment length may not matter as much as treatment frequency. However, RCTs of psychotherapy tend to test only time limited therapies and they may not reflect exactly what happens in the real world with diverse patients who have complex problems. Perhaps the most relevant research for clinicians may be what is called the dose-response studies. These are studies that indicate how many sessions it takes for patients to get better regardless of treatment length. The dose-response research showed that 50% of patients starting treatment in the dysfunctional range required 21 sessions to achieve clinically significant change. That also means that half of patients did not change meaningfully with 21 sessions of therapy. More than 35 sessions were necessary for 70% of patients to achieve clinically meaningful change (and still, 30% of patients did not benefit). It is likely that some patients get better with a few sessions, but as severity or complexity of problems increase so does the number of required sessions. To add to the complexity, optimal duration of therapy varies according to practice settings. For example, for CBT in controlled studies the average patient needed about 17 sessions to get better, while 35 sessions of CBT was necessary in real world settings for the average patient to improve (again, that means that 50% did not yet improve).

Practice Implications

The findings from this line of research of the optimal number of sessions suggest that it is difficult to translate findings from controlled trials to real world practice. Most RCTs limit therapy to a brief number of sessions whether patients get better or not. Some patients do improve with a few sessions but over half of patients require more than 21 sessions to achieve clinically meaningful change, and about 30% of patients require more than 35 sessions. There is some evidence that more sessions per week leads to better outcomes as well.

November 2021

Emotional Experiences of Psychotherapists

Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.

Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.

Practice Implications

Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Therapists are Not Equally Effective Across Sexual Orientations

Drinane, J. M., Roberts, T., Winderman, K., Freeman, V. F., & Wang, Y.-W. (2021, October 14). The myth of the safe space: Sexual orientation disparities in therapist effectiveness. Journal of Counselling Psychology. Advance online publication.

In general, differences between therapists account for 5% to 10% of the variance in client treatment outcomes. Some of these differences can be accounted for by therapists’ capacity to adjust to or to work with diverse client characteristics. For example, certain therapists more effectively espouse cultural humility and pursue opportunities for cultural conversations than other therapists, and this likely affects client outcomes. Most of the research on therapist effects related to diversity has focused on race/ethnicity. Very few studies to date have looked at therapist differences regarding sexual minority statuses. Therapists can engage in unhelpful practices including microaggressions toward sexual minority patients. Microaggressions can be unintended or subtle expressions of prejudice that are harmful to the recipient. Microaggressions that sexual minority patients experience may include communicating that one’s sexual orientation is a cause of distress, minimizing the importance of sexual orientation identity, and over-identification with LGBTQ clients. Further, patients with sexual minority statuses are at increased risk for adverse mental health outcomes possibly caused by the experience of minority stress related to stigma, prejudice, and discrimination. In this study, Drinane and colleagues a sample of 1,725 clients treated by 50 therapists in a university counselling center. About 17.7% of the client sample endorsed a sexual minority status. An unexpected finding was that sexual minority clients did not have worse mental outcomes than heterosexual clients. However, therapists varied in the extent to which their clients improved and how that improvement varied by sexual orientation status. Some therapists had queer clients who experienced more change than their heterosexual clients, whereas other therapists had heterosexual clients who experienced more change than their queer clients.

Practice Implications

The findings of this study indicate that therapists influence their clients outcomes differently based on the clients’ sexual orientation identity. Those therapists whose queer clients had worse outcomes than their heterosexual clients may be inadvertently engaging in microaggressions. Professional development that focuses on increasing the ability to consider sexual minority client experiences may lead psychotherapists to respond to sexual minority clients without prejudice. Therapists should consider how their own values shape their behaviors and interventions across client populations.
Psychological Treatments for Panic Disorder

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148

Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.

Practice Implications

The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.

October 2021

Therapist Dishonesty

Jackson, D., Farber, B.A., & Mandavia, A. (2021): The nature, motives, and perceived consequences of therapist dishonesty. Psychotherapy Research, DOI: 10.1080/10503307.2021.1933241

There is very little research or writing about therapist dishonesty with clients. Psychotherapy relies on clients to be honest to establish a therapeutic alliance – but what about therapists? Honesty is different from therapist self-disclosure. Self-disclosure refers to private information that therapists may or may not choose to share about themselves. Dishonesty, on the other hand are words or behaviors that are meant to deceive or mislead. Dishonesty can be covert (implying something that was not completely true) or overt (deliberately providing misleading information). Therapists might justify dishonesty as being carried out to protect their clients from harmful information, although some lying might be done by therapists to protect their own self esteem. In this survey of over 400 psychotherapists, Jackson and colleagues examined the topics, frequency, and some reasons why therapists were dishonest with clients. The therapists who responded to the survey had similar demographics to those practicing in the United States. They were on average 46.25 (SD = 15.59) years old, female (72.8%), mostly White (83.3%), working in private practice (62.6%), with an average of 16.48 (SD = 12.66) years of experience, and working from a range of theoretical orientations. The top reasons for therapist covert dishonesty included lying about feeling emotionally or physically unwell, feeling frustrated or bored with the client, or liking the client. The top reasons for therapist overt dishonesty included lying about feeling emotionally unwell, not remembering something a client said in a previous session, appointment availability, not having had conversations about the client with others, and not paying attention during a session. Over 91% of therapists indicated that they at least once gave the impression of paying attention when they were not, 88% implied they were not available for a session when they were, over 85% gave the impression that a client was making progress when they were not, 84% indicated they gave the false impression about a reason for being late to a session, and 65% at least once explicitly told a client something untrue about their own mental health history. Less than 1% of therapists reported that they were never dishonest with a client. Despite almost all therapists reporting being dishonest on occasion, therapist dishonesty tends to be relatively infrequent.

Practice Implications

Most of the time, if a therapist is dishonest with a client it is motivated by the consideration of a client’s best interest. On the one hand, therapists should be tactful by keeping in mind the needs and wellbeing of each client when considering what to disclose. However, research on therapist self-disclosure indicates that clients are more likely to disclose information if the therapist is honest about themselves. And some clinical writers suggest that therapists’ attempts to conceal negative feelings is an unproductive strategy that steers therapists and clients away from difficult conversations that might deepen the therapeutic relationship. As a general principle, therapists must consider whether the covert or overt dishonesty is truly in the service of the client or whether it is to protect the therapist’s self-esteem by not acknowledging their own missteps or limitations.

September 2021

Mindfulness-Based Interventions Among People of Color

Sun, S., Goldberg, S.B., Loucks, E.B., & Brewer, J.A. (2021). Mindfulness-based interventions among people of color: A systematic review and meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2021.1937369.

In the United States, people of color (POC) are disproportionately affected by structural inequalities related to racism such as high rates of incarceration, poor housing, and economic difficulties. Racial disparities also exist in health care such that POC are less likely to use health services thus resulting in more persistent health problems. Research has shown that mindfulness-based interventions (MBIs) may be effective in improving health outcomes of conditions that are prevalent among POC like psychiatric symptoms and cardiovascular disease. Some argue that MBIs are especially culturally relevant to POC because of the focus on overall well-being, the emphasis on resilience, and communally delivered formats. In this meta-analysis, Sun and colleagues systematically reviewed 24 randomized controlled trials with a total of over 2000 participants in which MBI was compared to no treatment or to an active control (a control group that was meant to be therapeutic). Only trials in which the study sample was predominantly (>75%) POC were included. At post-treatment, MBIs showed small but statistically significant outcomes compared to active controls (k = 16, g = 0.11, 95% CI = [0.04, 0.18], p = .002) and to no treatment (k=8, g = 0.26, 95%CI = [0.07, 0.45], p = .007). These are smaller effects than reported in other populations. Drop-out rates for POC receiving MBI was about 22%, which is similar to what is reported in the general psychotherapy outcome literature.

Practice Implications

The results suggest a modest effect of MBI for POC, and that the effects may be smaller than reported in studies with other populations. Only two of the studies reported culturally adapting MBI for POC. Psychotherapists might consider cultural adaptation of MBI or providing MBI from a multi-cultural orientation framework that includes therapists’ cultural humility, making the best of cultural opportunities in therapy, and developing cultural comfort and competence.

This month...

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December 2021

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November 2021

Practice Implications

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October 2021

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September 2021

Practice Implications

Psychotherapy Practice Research Network (PPRNet)